Systematically assessing the quality of dental electronic health record data for an investigation into oral health care disparities

OBJECTIVES

This work describes the process by which the quality of electronic health care data for a public health study was determined. The objectives were to adapt, develop, and implement data quality assessments (DQAs) based on the National Institutes of Health Pragmatic Trials Collaboratory (NIHPTC) data quality framework within the three domains of completeness, accuracy, and consistency, for an investigation into oral health care disparities of a preventive care program.

METHODS

Electronic health record data for eligible children in a dental accountable care organization of 30 offices, in Oregon, were extracted iteratively from January 1, 2014, through March 31, 2022. Baseline eligibility criteria included: children ages 0-18 with a baseline examination, Oregon home address, and either Medicaid or commercial dental benefits at least once between 2014 and 2108. Using the NIHPTC framework as a guide, DQAs were conducted throughout data element identification, extraction, staging, profiling, review, and documentation.

RESULTS

The data set included 91,487 subjects, 11 data tables comprising 75 data variables (columns), with a total of 6,861,525 data elements. Data completeness was 97.2%, the accuracy of EHR data elements in extracts was 100%, and consistency between offices was strong; 29 of 30 offices within 2 standard deviations of the mean (s = 94%).

CONCLUSIONS

The NIHPTC framework proved to be a useful approach, to identify, document, and characterize the dataset. The concepts of completeness, accuracy, and consistency were adapted by the multidisciplinary research team and the overall quality of the data are demonstrated to be of high quality.

Patients' Experiences of Dental Diagnostic Failures: A Qualitative Study Using Social Media

OBJECTIVE

Despite the many advancements made in patient safety over the past decade, combating diagnostic errors (DEs) remains a crucial, yet understudied initiative toward improvement. This study sought to understand the perception of dental patients who have experienced a dental diagnostic failure (DDF) and to identify patient-centered strategies to help reduce future occurrences of DDF.

METHODS

Through social media recruitment, we conducted a screening survey, initial assessment, and 67 individual patient interviews to capture the effects of misdiagnosis, missed diagnosis, or delayed diagnosis on patient lives. Audio recordings of patient interviews were transcribed, and a hybrid thematic analysis approach was used to capture details about 4 main domains of interest: the patient's DDF experience, contributing factors, impact, and strategies to mitigate future occurrences.

RESULTS

Dental patients endured prolonged suffering, disease progression, unnecessary treatments, and the development of new symptoms as a result of experiencing DE. Poor provider communication, inadequate time with provider, and lack of patient self-advocacy and health literacy were among the top attributes patients believed contributed to the development of a DE. Patients suggested that improvements in provider chairside manners, more detailed patient diagnostic workups, and improving personal self-advocacy; along with enhanced reporting systems, could help mitigate future DE.

CONCLUSIONS

This study demonstrates the valuable insight the patient perspective provides in understanding DEs, therefore aiding the development of strategies to help reduce the occurrences of future DDF events. Given the challenges patients expressed, there is a significant need to create an accessible reporting system that fosters constructive clinician learning.

Quality Measure Adherence and Oral Health Outcomes in Children

Importance

Process-based quality measures are generally intended to promote evidence-based practices that have been proven to improve outcomes. However, due to lack of standardized implementation of diagnostic codes in dentistry, assessing the association between process and oral health outcomes has been challenging.

Objective

To estimate the association of adhering to dental quality measures with patient oral health outcomes.

Design, Setting, and Participants

Using a target trial emulation, a causal inference framework, this retrospective cohort study estimated the difference in the risk of developing tooth decay between US children who adhered to process-based dental quality measures (receiving topical fluoride and sealant [treated groups]) and those who did not (control groups). Electronic health records of US children and adolescents aged 0 to 18 years from January 1, 2014, to December 31, 2020, were used. To emulate random treatment assignment based on baseline confounders, coarsened exact matching was used to produce covariate balance between the treated and control groups. A time-to-event regression model produced effect estimates, adjusting for time-varying covariates. Near-far matching was used to account for unmeasured confounders as a sensitivity analysis. Data were analyzed from May 1 to August 7, 2023.

Exposures

Adherence to dental quality measures.

Main Outcomes and Measures

Incidence of tooth decay.

Results

Among 69 212 US children aged between 0 and 18 years (mean [SD] age, 10.2 [5.0] years; 49.5% male, 50.4% female, and 0.1% unknown or transgender), 1930 (2.8%) were Asian, 2038 (2.9%) were Black, 8667 (12.5%) were Hispanic, 33 632 (48.6%) were White, and 22 945 (33.2%) were multiracial, other, or missing racial and ethnic group identification. Relative to control individuals, treated individuals were more likely to be at elevated risk of caries (fluoride measure: 16 453 [76.5%] vs 15 236 [39.8%]; sealant measure: 2264 [54.6%] vs 997 [44.0%]) and have regular dental visits (fluoride measure: 21 498 [100%] vs 13 741 [35.9%]; sealant measure: 1623 [39.2%] vs 871 [38.4%]). Adherence to quality measures was associated with reduced risk of tooth decay with adjusted hazard ratios of 0.82 (95% CI, 0.78- 0.86) for fluoride and 0.86 (95% CI, 0.76-0.97) for sealant in the matched cohort. Benefits of adhering to quality measures were greater among children at elevated vs low risk and with public vs commercial insurance for both measures.

Conclusions

In this cohort study, adhering to dental quality measures was associated with reduced risk of tooth decay, and benefits were greater among children at elevated risk and with public insurance. These findings provide insights in facilitating targeted application of quality measures or developing more tailored quality improvement initiatives.

Analysis of Race and Ethnicity, Socioeconomic Factors, and Tooth Decay Among US Children

Importance

While large oral health disparities remain by race and ethnicity among children, the associations of race, ethnicity, and mediating factors with oral health outcomes are poorly characterized. Identifying the pathways that explain these disparities would be critical to inform policies to effectively reduce them.

Objective

To measure racial and ethnic disparities in the risk of developing tooth decay and quantify relative contributions of factors mediating the observed disparities among US children.

Design, Setting, and Participants

This retrospective cohort study used electronic health records of US children from 2014 to 2020 to measure racial and ethnic disparities in the risk of tooth decay. Elastic net regularization was used to select variables to be included in the model among medical conditions, dental procedure types, and individual- and community-level socioeconomic factors. Data were analyzed from January 9 to April 28, 2023.

Exposures

Race and ethnicity of children.

Main Outcomes and Measures

The main outcome was diagnosis of tooth decay in either deciduous or permanent teeth, defined as at least 1 decayed, filled, or missing tooth due to caries. An Anderson-Gill model, a time-to-event model for recurrent tooth decay events with time-varying covariates, stratified by age groups (0-5, 6-10, and 11-18 years) was estimated. A nonlinear multiple additive regression tree-based mediation analysis quantified the relative contributions of factors underlying the observed racial and ethnic disparities.

Results

Among 61 083 children and adolescents aged 0 to 18 years at baseline (mean [SD] age, 9.9 [4.6] years; 30 773 [50.4%] female), 2654 Black individuals (4.3%), 11 213 Hispanic individuals (18.4%), 42 815 White individuals (70.1%), and 4401 individuals who identified as another race (eg, American Indian, Asian, and Hawaiian and Pacific Islander) (7.2%) were identified. Larger racial and ethnic disparities were observed among children aged 0 to 5 years compared with other age groups (Hispanic children: adjusted hazard ratio [aHR], 1.47; 95% CI, 1.40-1.54; Black children: aHR, 1.30; 95% CI, 1.19-1.42; other race children: aHR, 1.39; 95% CI, 1.29-1.49), compared with White children. For children aged 6 to 10 years, higher risk of tooth decay was observed for Black children (aHR, 1.09; 95% CI, 1.01-1.19) and Hispanic children (aHR, 1.12; 95% CI, 1.07-1.18) compared with White children. For adolescents aged 11 to 18 years, a higher risk of tooth decay was observed only in Black adolescents (aHR, 1.17; 95% CI, 1.06-1.30). A mediation analysis revealed that the association of race and ethnicity with time to first tooth decay became negligible, except for Hispanic and children of other race aged 0 to 5 years, suggesting that mediators explained most of the observed disparities. Insurance type explained the largest proportion of the disparity, ranging from 23.4% (95% CI, 19.8%-30.2%) to 78.9% (95% CI, 59.0%-114.1%), followed by dental procedures (receipt of topical fluoride and restorative procedures) and community-level factors (education attainment and Area Deprivation Index).

Conclusions

In this retrospective cohort study, large proportions of disparities in time to first tooth decay associated with race and ethnicity were explained by insurance type and dental procedure types among children and adolescents. These findings can be applied to develop targeted strategies to reduce oral health disparities.

Testing dental quality measures: Emergency department visits for nontraumatic dental conditions and subsequent follow-up dental visits

BACKGROUND

The goal of this study was to test the feasibility, reliability, and validity of the Dental Quality Alliance's adult dental quality measures for system-level implementation for ambulatory care sensitive (ACS) emergency department (ED) visits for nontraumatic dental conditions (NTDCs) in adults and follow-up after ED visits for NTDCs in adults.

METHODS

Medicaid enrollment and claims data from Oregon and Iowa were used for measure testing. Testing included validation of diagnosis codes in claims data through patient record reviews of ED visits and calculations of κ statistic, sensitivity, and specificity.

RESULTS

Adult Medicaid enrollees' ACS NTDC ED visits ranged from 209 through 310 per 100,000 member-months. In both states, patients in the age category 25 through 34 years and non-Hispanic Black patients had the highest rates of ACS ED visits for NTDCs. Only one-third of all ED visits were associated with a follow-up dental visit within 30 days, decreasing to approximately one-fifth with a 7-day follow-up. The agreement between the claims data and patient records for identification of ACS ED visits for NTDCs was 93%, κ statistic was 0.85, sensitivity was 92%, and specificity was 94%.

CONCLUSIONS

Testing revealed the feasibility, reliability, and validity of 2 DQA quality measures. Most beneficiaries did not have a follow-up with a dentist within 30 days of an ED visit.

PRACTICAL IMPLICATIONS

Adoption of quality measures by state Medicaid programs and other integrated care systems will enable active tracking of beneficiaries with ED visits for NTDCs and develop strategies to connect them to dental homes.

Dominant Power and the Concept of Caste: Implications for Dentistry and Oral Health Inequality

This paper explores the issues of caste and casteism in the U.S. as described by Pulitzer Prize winning journalist Isabel Wilkerson in her 2020 book "Caste: The Origin of Our Discontents". Wilkerson argues that a caste system not only exists in the U.S. but operates as a hidden force affecting social inequality. The paper draws on Wilkerson's work to explore caste as an analytical concept. It begins by defining caste and casteism in contrast with racism, the eight pillars of a caste system, the consequences of casteism, and the psychological drivers of casteism. The paper then applies to concept of caste to understanding power, dentistry, and oral health inequality. The paper concludes by emphasizing that the concept of caste and its relationship to oral health inequality must be understood it if we want to create real social change.

Comparison of Dental Care Visits Before and After Adoption of a Policy to Expand the Dental Workforce in Minnesota

Question

Is expansion of the dental workforce by authorizing dental therapists in Minnesota associated with increased dental care use?

Findings

In this cross-sectional study of 2 613 716 adults, authorizing dental therapists was associated with an increase in dental care use among low-income adults. In subgroup analysis, authorizing dental therapists was associated with an increase in dental visits for White adults, but no significant change in use was detected for other racial and ethnic groups.

Meaning

Expanding the dental workforce in Minnesota by authorizing dental therapists was associated with improved dental care use, particularly among low-income adults; however, racial and ethnic disparities in dental use persist.

Importance

Currently, 13 states and tribal nations have expanded their dental workforce by adopting use of dental therapists. To date, there has been no evaluation of the influence of this policy on dental care use.

Objective

To assess changes in dental care use in Minnesota after the implementation of the policy to authorize dental therapists in 2009.

Design, Setting, and Participants

In this cross-sectional study of 2 613 716 adults aged 18 years and older, a synthetic control method was used to compare changes in dental care use after the authorization of the policy in Minnesota relative to a synthetic control of nonadopting states. Data from the Behavioral Risk Factor Surveillance System from 2006 to 2018 were analyzed. Data analysis was conducted from June 1, 2021, to December 18, 2021.

Exposure

Authorization of dental therapy.

Main Outcomes and Measures

Self-reported indicator for whether a respondent had visited a dentist or a dental clinic in the past 12 months.

Results

Among 2 613 716 adults aged 18 years or older, the mean (SD) age at baseline was 46.0 (17.7) years, 396 501 were women (weighted percentage, 51.3%), 503 197 were White (weighted percentage, 67.9%), 54 568 were Black (weighted percentage, 10.1%), 39 282 were Hispanic (weighted percentage, 14.5%), and 34 739 were other race (weighted percentage, 6.7%). The proportion of adults visiting a dentist before the authorization of dental therapists in Minnesota was 76.2% (95% CI, 75.0%-77.4%) in the full sample, 61.5% (95% CI, 58.4%-64.6%) for low-income adults, and 58.4% (95% CI, 53.0%-63.5%) among Medicaid-eligible adults. Authorizing dental therapists in Minnesota was associated with an increase of 7.3 percentage points (95% CI, 5.0-9.5 percentage points) in dental care use among low-income adults, a relative increase of 12.5% (95% CI, 8.6%-16.4%), and an increase of 6.2 percentage points (95% CI, 2.4-10.0 percentage points) among Medicaid-eligible adults, a relative increase of 10.5% (95% CI, 3.9%-17.0%). In addition, the policy was associated with an increase in dental visits among White adults (low-income sample, 10.8 percentage points [95% CI, 8.5-13.0 percentage points]; Medicaid sample, 13.5 percentage points [95% CI, 9.1-17.9 percentage points]), with no corresponding increases among other racial and ethnic groups in the low-income and Medicaid population.

Conclusions and Relevance

In this cross-sectional study, expanding the dental workforce through authorization of dental therapists appeared to be associated with an increase in dental visits. In Minnesota, the policy was associated with improved access to dental care among low-income adults overall. However, racial and ethnic disparities in dental use persist.

Slipping through the cracks: Just how underrepresented are minorities within the dental specialties?

Objective

There is a lack of diversity in the dental workforce. Efforts to enhance underrepresented minority (URM) recruitment and retention within dental school exist, but little effort has been made to track URM providers through education and practice. This study assesses the status of workforce diversity in the dental specialties and the predictors of URM dentist specialization.

Methods

The primary data used were a 2012 national sample survey of Hispanic/Latino (H/L), Black, or American Indian/Alaska Native (AI/AN) dentists in the US, supplemented by publicly available workforce data. Descriptive and multivariate statistical analyses were performed to describe the demographic composition of URM clinical general and specialist dentists and analyze changes in proportions of URMs specializing among age cohorts, differences in specific type of specialization, and racial concordance between specialists and their patients.

Results

The pathway continues to winnow with fewer URM dentists in specialty practice. Among all URM clinical dentists being first in his/her family to obtain a college degree, having a strong desire to work in his/her own cultural community or joining a loan repayment program due to debt load independently predicted lower odds of specialization. Alternatively, being initially foreign trained as a dentist and valuing professional training were independently predictive of higher odds of specialization.

Conclusion

The lack of diversity within the dental specialties is a critical flaw in our education and care delivery systems demanding clear actions toward improving the pathway into residency programs for URM students.

American Indian/Alaska Native, Black, and Hispanic dentists' experiences of discrimination

OBJECTIVE

Little is known about the scope and role of discriminatory experiences in dentistry. The purpose of this study is to document the experiences that American Indian/Alaska Native (AI/AN), Black, and Hispanic dentists have had with discrimination.

METHODS

This study reports data from a 2012 nationally representative study of dentists documenting experiences with discrimination during their dental careers or during dental school by the setting of the discrimination, the providers' education, and geographic location. This study does not differentiate between levels of discrimination and focuses holisticly on the experience of any discrimination.

RESULTS

Seventy-two percent of surveyed dentists reported any experience with discrimination in a dental setting. The experiences varied by race/ethnicity, with 49% of AI/AN, 86% Black, and 59% of Hispanic dentists reporting any discriminatory experiences. Racial/ethnic discrimination was reported two times greater than any other type.

CONCLUSIONS

Experiences with racial/ethnic discrimination are prevalent among AI/AN, Black, and Hispanic dentists, suggesting that as a profession work is needed to end discrimination and foster belonging.

Caries Risk Documentation And Prevention: eMeasures For Dental Electronic Health Records

BACKGROUND

Longitudinal patient level data available in the electronic health record (EHR) allows for the development, implementation, and validations of dental quality measures (eMeasures).

OBJECTIVE

We report the feasibility and validity of implementing two eMeasures. The eMeasures determined the proportion of patients receiving a caries risk assessment (eCRA) and corresponding appropriate risk-based preventative treatments for patients at elevated risk of caries (appropriateness of care [eAoC]) in two academic institutions and one accountable care organization, in the 2019 reporting year.

METHODS

Both eMeasures define the numerator and denominator beginning at the patient level, populations' specifications, and validated the automated queries. For eCRA, patients who completed a comprehensive or periodic oral evaluation formed the denominator, and patients of any age who received a CRA formed the numerator. The eAoC evaluated the proportion of patients at elevated caries risk who received the corresponding appropriate risk-based preventative treatments.

RESULTS

EHR automated queries identified in three sites 269,536 patients who met the inclusion criteria for receiving a CRA. The overall proportion of patients who received a CRA was 94.4% (eCRA). In eAoC, patients at elevated caries risk levels (moderate, high, or extreme) received fluoride preventive treatment ranging from 56 to 93.8%. For patients at high and extreme risk, antimicrobials were prescribed more frequently site 3 (80.6%) than sites 2 (16.7%) and 1 (2.9%).

CONCLUSION

Patient-level data available in the EHRs can be used to implement process-of-care dental eCRA and AoC, eAoC measures identify gaps in clinical practice. EHR-based measures can be useful in improving delivery of evidence-based preventative treatments to reduce risk, prevent tooth decay, and improve oral health.

Dental Therapists in the United States: Health Equity, Advancing

BACKGROUND

Dental therapists (DTs) are primary care dental providers, used globally, and were introduced in the United States (US) in 2005. DTs have now been adopted in 13 states and several Tribal nations.

OBJECTIVES

The objective of this study is to qualitatively examine the drivers and outcomes of the US dental therapy movement through a health equity lens, including community engagement, implementation and dissemination, and access to oral health care.

METHODS

The study compiled a comprehensive document library on the dental therapy movement including literature, grant documents, media and press, and gray literature. Key stakeholder interviews were conducted across the spectrum of engagement in the movement. Dedoose software was used for qualitative coding. Themes were assessed within a holistic model of oral health equity.

FINDINGS

Health equity is a driving force for dental therapy adoption. Community engagement has been evident in diverse statewide coalitions. National accreditation standards for education programs that can be deployed in 3 years without an advanced degree reduces educational barriers for improving workforce diversity. Safe, high-quality care, improvements in access, and patient acceptability have been well documented for DTs in practice.

CONCLUSION

Having firmly taken root politically, the impact of the dental therapy movement in the US, and the long-term health impacts, will depend on the path of implementation and a sustained commitment to the health equity principle.

Dental public health post-graduate trainees in the US: Experiences, challenges, and opportunities-A qualitative study

OBJECTIVES

The goal of this study was to explore challenges and opportunities that dental public health (DPH) residents and recent graduates experienced during and after their residency training programs in the US.

METHODS

In this qualitative study, to recruit participants, study invitations were distributed to 93 DPH postgraduate trainees via social media, email, and an online DPH nationwide course in 2019. Semi-structured in-depth interviews were conducted through Zoom audioconference. The interviews were conducted until thematic saturation was achieved. The audio-recorded interviews were transcribed and crosschecked to ensure accuracy. The interviews were coded using grounded theory. A qualitative analysis software (ATLAS.ti 8.0) was used to facilitate coding and organizing data extraction from transcripts.

RESULTS

Eighteen DPH postgraduate trainees from 12 DPH residency programs participated and completed the interview. DPH trainees had experienced educational and financial challenges, difficulty finding DPH-related jobs after graduation, and a complex board examination preparation process.

CONCLUSION

DPH postgraduate trainees and especially foreign-trained dentists experienced serious challenges during and after their postgraduate residency programs. Opportunities exist to enhance the strength of DPH programs to build a competent DPH workforce.

Assessing the completeness of periodontal disease documentation in the EHR: a first step in measuring the quality of care

Background

Our objective was to measure the proportion of patients for which comprehensive periodontal charting, periodontal disease risk factors (diabetes status, tobacco use, and oral home care compliance), and periodontal diagnoses were documented in the electronic health record (EHR). We developed an EHR-based quality measure to assess how well four dental institutions documented periodontal disease-related information. An automated database script was developed and implemented in the EHR at each institution. The measure was validated by comparing the findings from the measure with a manual review of charts.

Results

The overall measure scores varied significantly across the four institutions (institution 1 = 20.47%, institution 2 = 0.97%, institution 3 = 22.27% institution 4 = 99.49%, p-value < 0.0001). The largest gaps in documentation were related to periodontal diagnoses and capturing oral homecare compliance. A random sample of 1224 charts were manually reviewed and showed excellent validity when compared with the data generated from the EHR-based measure (Sensitivity, Specificity, PPV, and NPV > 80%).

Conclusion

Our results demonstrate the feasibility of developing automated data extraction scripts using structured data from EHRs, and successfully implementing these to identify and measure the periodontal documentation completeness within and across different dental institutions.

Medicare Support for Dental and Podiatry Graduate Medical Education Programs

IMPORTANCE

Oral health care faces ongoing workforce challenges that affect patient access and outcomes. While the Medicare program provides an estimated $14.6 billion annually in graduate medical education (GME) payments to teaching hospitals, including explicit support for dental and podiatry programs, little is known about the level or distribution of this public investment in the oral health and podiatry workforce.

OBJECTIVE

To examine Medicare GME payments to teaching hospitals for dental and podiatry residents from 1998 to 2018, as well as the distribution of federal support among states, territories, and the District of Columbia.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study was conducted using data from 1252 US teaching hospitals. Data were analyzed from May through August 2020.

EXPOSURES

Dental and podiatry residency training.

MAIN OUTCOMES AND MEASURES

Medicare dental and podiatry GME payments were examined.

RESULTS

Among 1252 teaching hospitals, Medicare provided nearly $730 million in dental and podiatry GME payments in 2018. From 1998 to 2018, the number of residents supported more than doubled, increasing from 2340 residents to 4856 residents, for a 2.1-fold increase, while Medicare payments for dental and podiatry GME increased from $279 950 531 to $729 277 090, for a 2.6-fold increase. In 2018, an estimated 3504 of 4856 supported positions (72.2%) were dental. Medicare GME payments varied widely among states, territories, and the District of Columbia, with per capita payments by state, territory, and district population ranging from $0.05 in Puerto Rico to $14.24 in New York, while 6 states received no support for dental or podiatry residency programs.

CONCLUSIONS AND RELEVANCE

These findings suggest that dental and podiatry GME represents a substantial public investment, and deliberate policy decisions are needed to target this nearly $730 million and growing investment to address the nation's priority oral and podiatry health needs.

Measuring sealant placement in children at the dental practice level

Background.

Although sealants are an established and recommended caries-preventive treatment, many children still fail to receive them. In addition, research has shown that existing measures underestimate care by overlooking the sealable potential of teeth before evaluating care. To address this, the authors designed and evaluated 3 novel dental electronic health record–based clinical quality measures that evaluate sealant care only after assessing the sealable potential of teeth.

Methods.

Measure I recorded the proportion of patients with sealable teeth who received sealants. Measure II recorded the proportion of patients who had at least 1 of their sealable teeth sealed. Measure III recorded the proportion of patients who received sealant on all of their sealable teeth.

Results.

On average, 48.1% of 6- through 9-year-old children received 1 or more sealants compared with 32.4% of 10- through 14-year-olds (measure I). The average measure score decreased for patients who received sealants for at least 1 of their sealable teeth (measure II) (43.2% for 6- through 9-year-olds and 28.4% for 10- through 14-year-olds). Fewer children received sealants on all eligible teeth (measure III) (35.5% of 6- through 9-year-olds and 21% of 10- through 14-year-olds received sealant on all eligible teeth). Among the 48.5% who were at elevated caries risk, the sealant rates were higher across all 3 measures.

Conclusions.

A valid and actionable practice-based sealant electronic measure that evaluates sealant treatment among the eligible population, both at the patient level and the tooth level, has been developed.

Practical Implications.

The measure developed in this work provides practices with patient-centered and actionable sealant quality measures that aim to improve oral health outcomes.

Dental Workforce Trends: A National Study of Gender Diversity and Practice Patterns

The dental workforce is increasingly gender diverse. This study analyzed gender differences in dental practice using the American Dental Association's 2010-2016 Masterfile and the 2017 Survey of Dental Practice. Between 2010 and 2016, the proportion of women working in dentistry increased from 24.5% to 29.8%. Overall, female dentists were more racially/ethnically diverse, more likely to be foreign-trained, and more likely to work in pediatric dentistry than male dentists. The likelihood of female dentists working as employees, part-time, and/or in metropolitan areas was 1.2 to 4.2 times greater compared with male dentists. Female solo practitioners were 1.2 to 1.8 times more likely to provide services to children and patients covered by public insurance than male solo practitioners. Gender diversification in dentistry and other factors, including generational differences and changes in the dental service delivery system and public policy, will continue to reshape the delivery of oral health services.

Opioid prescribing patterns after dental visits among beneficiaries of Medicaid in Washington state in 2014 and 2015

BACKGROUND

Dentists contribute to the prevailing opioid epidemic in the United States. Concerning the population enrolled in Medicaid, little is known about dentists' opioid prescribing.

METHODS

The authors performed a retrospective cohort study of beneficiaries of Medicaid in Washington state with dental claims in 2014 and 2015. The primary outcome was the proportion of dental visits associated with an opioid prescription. The authors categorized visits as invasive or noninvasive by using procedure codes and each beneficiary as being at low or high risk by using his or her prescription history from the prescription drug monitoring program.

RESULTS

A total of 126,660 (10.3%) of all dental visits, most of which were invasive (66.9%), among the population enrolled in Medicaid in Washington state was associated with opioid prescriptions. However, noninvasive dental visits and visits for beneficiaries who had prior high-risk prescription use were associated with significantly higher mean days' supply and mean quantity of opioids prescribed. Results from the multivariate logistic regression showed that the probability of having an opioid-associated visit increased by 35.6 percentage points when the procedures were invasive and by 11.1 percentage points when the beneficiary had prior high-risk prescription use.

CONCLUSIONS

This baseline of opioid prescribing patterns after dental visits among the population enrolled in Medicaid in Washington state in 2014 and 2015 can inform future studies in which the investigators examine the effect of policies on opioid prescribing patterns and reasons for the variability in the dosage and duration of opioid prescriptions associated with noninvasive visits.

PRACTICAL IMPLICATIONS

Dentists must exercise caution when prescribing opioids during invasive visits and to patients with prior high-risk prescription use.

Number of Pregnant Women at Four Dental Clinics and the Care They Received: A Dental Quality eMeasure Evaluation

Process-of-care quality measure research can be used to identify gaps in the delivery of dental services to pregnant patients. The aim of this study was to evaluate the types of dental services that pregnant patients received in four dental clinics over five years as documented in the electronic health record (EHR). To accomplish this objective, the authors modified and validated a previously published claims-based dental quality measure for EHR use. After the electronic dental quality measure specifications were defined, the number of pregnant patients was calculated at three academic dental institutions and one large accountable care organization, and the types of dental care services they received over a five-year period (2013-17) were determined. Calibrated reviewers at each institution independently reviewed a sub-sample of patient charts to validate the information obtained from EHR queries, and the concordance between manual chart reviews and EHR query reports was analyzed. Of the 335,078 women aged 15-44 years who received care at the four clinics for the five reporting years, 3.9% (n=13,026) were pregnant. Among these pregnant patients, 48.9% (n=6,366) received a periodic dental examination; 30.0% (n=3,909) received a comprehensive dental exam; and 21.5% (n=2,799) received additional dental services, irrespective of comprehensive or periodic oral evaluations. Overall, the mean proportion of pregnant patients seeking care in these academic dental and group practice clinics was low, but 78.9% of them received either a periodic or comprehensive oral evaluation. Given the importance of oral health care during pregnancy, these findings suggest a need for curriculum development to incorporate prenatal oral health education in the training of dental students.

Tobacco screening and cessation efforts by dental providers: A quality measure evaluation

OBJECTIVES

The purpose of this study was to adapt, test, and evaluate the implementation of a primary care "Preventive care and Screening" meaningful use quality measure for tobacco use, in dental institutions. We determined the percentage of dental patients screened for tobacco use, and the percentage of tobacco users who received cessation counseling.

METHODS

We implemented the dental quality measure (DQM), in three dental schools and a large dental accountable care organization. An automated electronic health record (EHR) query identified patients 18 years and older who were screened for tobacco use one or more times within 24 months, and who received cessation counseling intervention if identified as a tobacco user. We evaluated EHR query performance with a manual review of a subsample of charts.

RESULTS

Across all four sites, in the reporting calendar year of 2015, a total of 143,675 patients met the inclusion criteria for the study. Within 24 months, including 2014 and 2015 calendar years, percentages of tobacco screening ranged from 79.7 to 99.9 percent, while cessation intervention percentages varied from 1 to 81 percent among sites. By employing DQM research methodology, we identified intervention gaps in clinical practice.

CONCLUSIONS

We demonstrated the successful implementation of a DQM to evaluate screening rates for tobacco use and cessation intervention. There is substantial variation in the cessation intervention rates across sites, and these results are a call for action for the dental profession to employ tobacco evidence-based cessation strategies to improve oral health and general health outcomes.

Preventing Oral Disease: Alternative Providers and Places to Address This Commonplace Condition

Oral health disease in young children has not decreased, despite adequate modalities for treatment and prevention. Because many children may not see a dentist before oral disease has begun, disease progression can be expected, affecting short-term and long-term oral health. However, most children are seen by other health professionals frequently in their youngest years, providing a unique opportunity to help weave a safety net of oral health care until they are established in a dental home. This article details ways primary care providers can promote oral health, including ways to integrate ancillary dental professionals into the primary care home.

Assessing the validity of existing dental sealant quality measures

BACKGROUND

Although sealants are highly effective in preventing caries in children, placement rates continue to be low. The authors' goals were to implement and assess the performance of 2 existing sealant quality measures against a manual audit of charts at 4 dental institutions and to identify measurement gaps that may be filled by using data from electronic health records.

METHODS

The authors evaluated the performance of 2 quality measures designed for claims-based data: the Dental Quality Alliance (DQA) sealant measure, which includes patients at risk of developing elevated caries, and the Oregon Health Authority (OHA) sealant measure (irrespective of caries risk). The authors adapted and validated these measures at 4 sites: 3 dental schools and 1 large dental accountable care organization.

RESULTS

The overall modified DQA and modified OHA measure scores in the 6- through 9-year-old age group were 37.0% and 31.6% and in the 10- through 14-year-old age group were 15.8% and 6.6%, respectively. Results from the manual review of charts showed that 67.6% of children who did not receive sealants did not have any teeth to seal because their molars had not yet erupted, had been extracted, had been sealed previously, or had existing caries or restorations.

CONCLUSIONS

Both the DQA and OHA measures, which rely mainly on Current Dental Terminology procedure codes, led to underestimation of the care delivered from a practice perspective. Future sealant quality measures should exclude patients whose teeth cannot be sealed.

PRACTICAL IMPLICATIONS

This study's results support the suitability of using electronic health record data for assessing the quality of oral health care, particularly for measuring sealant placement in children.

Pediatric Workforce Issues

Untreated dental disease remains one of the most prevalent health conditions for children, driven in part by disparities in access to care. This article examines evidence-based workforce strategies being used to facilitate better access to pediatric health services and to improve oral health status and outcomes for children. The workforce strategies described in this article include promising new models in the dental field, with new and existing providers as well as emerging workforce models outside of the dental field. Case studies for some of these workforce strategies are also presented. Future directions and health policy implications are considered.

The American Indian and Alaska Native dentist workforce in the United States

OBJECTIVES

The purpose of this article is to describe the American Indian/Alaska Native (AI/AN) dentist workforce, the general practice patterns of these providers, and their contributions to oral health care for AI/AN and underserved patients.

METHODS

A national sample survey of underrepresented minority dentists was conducted in 2012 and received a 34 percent response rate for self-reported AI/AN dentists. Data were weighted for selection and response bias to be nationally representative. Descriptive and multivariable statistics were computed to provide a workforce profile. Comparisons to Census data and published information on dental students and dentists were used to examine practice patterns.

RESULTS

The AI/AN dentist workforce (weighted n = 442) is very diverse with 55 reported individual tribal affiliations. Tribal heritage was provided by 95.7 percent of AI/AN dentists (n = 423), and of these, 93.9 percent (n = 400) reported an affiliation with only one tribe. The largest share of AI/AN dentists were born in the United States (98.2 percent, n = 434), married (75.6 percent, n = 333), and had dependent children under age 18 (52.0 percent, n = 222). Only 0.9 percent (n = 4) of AI/AN dentists spoke a traditional AI/AN language in patient care, while 10.6 percent (n = 46) were raised on tribal land or reservation. Initial practice in the Indian Health Service was reported by 15.8 percent of AI/AN dentists while 16.2 percent report currently practicing in a safety-net setting, and 42.0 percent report working in a practice that primarily serves underserved patients.

CONCLUSIONS

AI/AN dentists provide a disproportionate share of care for AI/AN populations, yet the number of AI/AN dentists would need to increase 7.4-fold in order to meet population parity.

The Hispanic and Latino dentist workforce in the United States

OBJECTIVES

The purpose of this paper is to describe the Hispanic/Latino (H/L) dentist workforce, their general practice patterns, and their contributions to oral health care for H/L and underserved patients.

METHODS

A national sample survey of underrepresented minority dentists was conducted in 2012 and received a 35.4 percent response rate for self-reported H/L dentists. Data were weighted for selection and response bias to be nationally representative. A workforce profile of H/L dentists was created using descriptive and multivariable statistics and published data.

RESULTS

Among all H/L dentists (weighted n = 5,748), 31.9 percent self-identify their origin as Mexican, 13.4 percent as Puerto Rican, 13.0 percent as Cuban, and 41.7 percent as another H/L group. The largest share of H/L dentists are male, married, and have children under age 18. Fifty percent of H/L dentists are foreign-born and 25 percent are foreign-trained. H/L dentists report higher than average educational debt, with those completing International Dentist Programs reporting the highest debt load. Sixty-nine percent of clinically active H/L dentists own their own practices, and 85 percent speak Spanish in their practice. Among clinical H/L dentists, 7 percent work in safety-net settings, 40 percent primarily treat underserved populations, and, on average, 42 percent of their patient population is H/L.

CONCLUSIONS

H/L dental providers are underrepresented in the dentist population, and those that are in practice shoulder a disproportionate share of dental care for minority and underserved communities. Improving the workforce diversity of dental providers is a critical part of strategy to address the high burden of dental disease in the H/L population.

The Black dentist workforce in the United States

OBJECTIVES

The purpose of this paper is to describe the Black dentist workforce, the practice patterns of providers, and their contributions to oral health care for minority and underserved patients.

METHODS

A national sample survey of underrepresented minority dentists was conducted in 2012 and received a 32.6 percent response rate for self-reported Black dentists. Data were weighted for selection and response bias to be nationally representative. Descriptive and multivariable statistics were computed to provide a workforce profile of Black dentists. National comparisons are provided from published data.

RESULTS

Among all Black dentists (weighted n = 6,254), 76.6 percent self-identify as African-American, 13.2 percent as African, and 10.3 percent as Afro-Caribbean. The largest share of Black dentists are male, married, heterosexual, born in the United States and raised in a medium to large city. One third of Black dentists were the first in their family to graduate from college. Black dentists report higher average educational debt than all dental students, with graduates from International Dentist Programs having the greatest debt. Traditional practices (i.e., private practices) dominate, with 67.1 percent of Black dentists starting out in this setting and 73.5 percent currently in the setting. Black dentists care for a disproportionate share of Black patients, with an average patient mix that is 44.9 percent Black. Two in five Black dentists reported their patient pool is made up of more than 50 percent Black patients.

CONCLUSIONS

The underrepresentation for Black dentists is extraordinary, and the Black dentists that are in practice are shouldering a disproportionate share of dental care for minority and underserved communities.

Provider Attitudes Toward the Implementation of Clinical Decision Support Tools in Dental Practice

PURPOSE

The objective of this paper is to assess clinical dental providers' baseline knowledge and attitudes about the implementation of three clinical decision support (CDS) tools built into the electronic health record (EHR) of a multi-specialty group dental practice.

PROCEDURES

An electronic survey designed to examine predisposing factors for acceptance of EHR-based tools, caries and periodontal disease management by risk assessment and a risk assessment-based Proactive Dental Care Plan, was distributed to all Willamette Dental Group (WDG) employees. The survey collected demographic data, along with measures of job experience and satisfaction, comfort with dental information technology, and attitudes and knowledge of each CDS tool. WDG provided data on site-level patient and financing mix, patient satisfaction data, employee role (e.g. dentist) and tenure with company. The survey was conducted 3 months prior to the rollout of the CDS tools in November 2013. The survey was distributed electronically to all WDG employees (n = 1166), of whom 58.5% (n = 682) were clinicians, located in 53 sites in Oregon, Washington and Idaho. The overall response rate was 79.8% (n = 930), with a response rate of 83.1% (n = 567) from all clinicians. Of these, 24.3% were general and specialist dentists (n = 138); 26.6% were dental hygienists (n = 151), and 49% were dental assistants (n = 278).

PRINCIPAL FINDINGS

The clinicians surveyed reported being highly amenable to implementation of the three CDS tools. Clinicians' attitudes reflected higher expected improvement in patient care and quality than in business processes due to the implementation. The clinician characteristics most strongly correlated with a positive attitude toward the CDS tool implementation (as measured on Likert scale 1 = low to 5 = high) included satisfaction with the EHR (0.499, p < 0.001), job satisfaction (0.458, p < 0.001), finding change to be exciting (0.398, p < 0.001), degree of control perceived over work (0.352, p < 0.001), and a perception of having adequate tools to get work done (0.340, p < 0.001). Higher reported frequency (scale 1 = never, 7 = always) of feeling burned out (-0.297, p < 0.001), feeling emotionally drained (-0.265, p < 0.001), and feeling work is a strain (-0.205, p < 0.001) had the greatest correlation with negative attitudes.

CONCLUSION

This is the first study to examine dental provider attitudes toward the implementation of CDS tools incorporated within an electronic health record. Provider attitudes toward CDS tools can shape the entire implementation process for better or worse. This study contributes to the literature by providing an understanding of factors related to positive attitudes at the outset of a system change and can help guide organizational administrators to better prepare their workforce and organization for adoption of evidence-based dentistry tools such as a CDS system.

Shaking up the dental safety-net: elimination of optional adult dental Medicaid benefits in California

In July 2009, California eliminated funding for most adult non-emergency Medicaid dental benefits (Denti-Cal). This paper presents the findings from a qualitative assessment of the impacts of the Denti-Cal cuts on California's oral health safety-net. Interviews were conducted with dental safety-net providers throughout the state, including public health departments, community health centers, dental schools, Native American health clinics, and private providers, and were coded thematically using Atlas.ti. Safety-net providers reported decreased utilization by Denti-Cal-eligible adults, who now primarily seek emergency dental services, and reported shifting to focus on pediatric and privately-insured patients. Significant changes were reported in safety-net clinic finances, operations, and ability to refer. The impact of the Denti-Cal cuts has been distributed unevenly across the safety-net, with private providers and County Health Departments bearing the highest burden.

Tracking workforce diversity in dentistry: importance, methods, and challenges

OBJECTIVES

The objectives of this paper are to describe sources of data on underrepresented minority (URM) dental providers and to perform a structured critique of primary survey research on African American (AA), Hispanic/Latino (HL), and American Indian/Alaska Native (AI/AN) dentists.

METHODS

A national sample survey was conducted between October 2012 and March 2013, and secondary datasets were assessed for comparability. The survey used 21 sampling frames, with censuses of AI/AN and nonurban dentists, and assessed demographics, education, practice history, patient population, volunteerism, experiences with discrimination, and opinions on issues in dentistry. The survey was developed with constituent input, pilot-tested, and distributed online and through US mail with three reminder postcards, phone, and email follow-up. Continuing education credit and entry to a prize drawing were provided for participation.

RESULTS

Existing data sources cannot answer critical research questions about URM dentists. Using best practices, the survey received a 34 percent adjusted response rate. Selection likelihood and measurable response bias were adjusted for using base and poststratification weights.

CONCLUSIONS

The survey design was consistent with best practices, and our response analytics provide high confidence that the survey produced data representative of the URM dentist population. Enhanced study design, content, and response rates of existing survey efforts would be needed to provide a more robust body of knowledge on URM providers, perspectives, and practices.

Dental workforce capacity and California's expanding pediatric Medicaid population

The number of children eligible for Medicaid dental coverage in California will increase to nearly 5 million because of the Affordable Care Act the transition of nearly 880,000 children from California's Children's Health Insurance Program (CHIP) to Medicaid. This study assesses the dental capacity to serve this population. Supply projections indicate that deficits are likely in rural and urban counties after the CHIP population is and the ACA is fully implemented.

Maintaining oral health across the life span

Oral health is directly related to systemic health, yet many Americans have limited to no access to dental health professionals. Nurse practitioners are in an excellent position to fill this void by providing caries risk assessments, chemical therapy to prevent progression of caries, and appropriate patient education to prevent caries.

Building leadership among laboratory-based and clinical and translational researchers: the University of California, San Francisco experience

In 2005 the University of California, San Francisco (UCSF) implemented the Scientific Leadership and Management (SLM) course, a 2-day leadership training program to assist laboratory-based postdoctoral scholars in their transition to independent researchers managing their own research programs. In 2011, the course was expanded to clinical and translational junior faculty and fellows. The course enrollment was increased from approximate 100 to 123 participants at the same time. Based on course evaluations, the number and percent of women participants appears to have increased over time from 40% (n = 33) in 2007 to 53% (n = 58) in 2011. Course evaluations also indicated that participants found the course to be relevant and valuable in their transition to academic leadership. This paper describes the background, structure, and content of the SLM and reports on participant evaluations of the course offerings from 2007 through 2011.

The effect of different methods of remuneration on the behaviour of primary care dentists

BACKGROUND

Methods of remuneration have been linked with the professional behaviour of primary care physicians. In dentistry, this can be exacerbated as clinicians operate their practices as businesses and take the full financial risk of the provision of services. The main methods for remunerating primary care dentists include fee-for-service, fixed salary and capitation payments. The aim of this review was to determine the impact that these remuneration mechanisms have upon primary care dentists' behaviour.

OBJECTIVES

To evaluate the effects of different methods of remuneration on the level and mix of activities provided by primary care dentists and the impact this has on patient outcomes.

SEARCH METHODS

We searched the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 7, 2013); MEDLINE (Ovid) (1947 to 11 June 2013); EMBASE (Ovid) (1947 to 11 June 2013); EconLit (1969 to 11 June 2013); the NHS Economic Evaluation Database (EED) (11 June 2013); and the Health Economic Evaluations Database (HEED) (11 June 2013). We conducted cited reference searches for the included studies in ISI Web of Knowledge; searched grey literature sources; handsearched selected journals; and contacted authors of relevant studies.

SELECTION CRITERIA

Primary care dentists were defined as clinicians that deliver routine or mainstream dental care in a primary care environment. We included randomised controlled trials (RCTs), non-randomised controlled clinical trials (NRCTs), controlled before-after (CBA) studies and interrupted time series (ITS) studies. The methods of remuneration that we considered were: fee-for-service, fixed salary and capitation payments. Primary outcome measures were: measures of clinical activity; volume of clinical activity undertaken; time taken and clinical session length, or both; clinician type utilised; measures of health service utilisation; access and attendance as a proportion of the population; re-attendance rates; recall frequency; levels of oral health inequalities; non-attendance rates; healthcare costs; measures of patient outcomes; disease reduction; health maintenance; and patient satisfaction. We also considered measures of practice profitability/income and any reported unintended effects of the included methods of remuneration.

DATA COLLECTION AND ANALYSIS

Three of the review authors (PRB, JP, AMG) independently reviewed titles and abstracts and resolved disagreements by discussion. The same three review authors undertook data extraction and assessed the quality of the evidence from all the studies that met the selection criteria, according to Cochrane Collaboration procedures.

MAIN RESULTS

Two cluster-RCTs, with data from 503 dental practices, representing 821 dentists and 4771 patients, met the selection criteria. We judged the risk of bias to be high for both studies and the overall quality of the evidence was low/very low for all outcomes, as assessed using the GRADE approach.One study used a factorial design to investigate the impact of fee-for-service and an educational intervention on the placement of fissure sealants in permanent molar teeth. The authors reported a statistically significant increase in clinical activity in the arm that was incentivised with a fee-for-service payment. However, the study was conducted in the four most deprived areas of Scotland, so the applicability of the findings to other settings may be limited. The study did not report data on measures of health service utilisation or measures of patient outcomes.The second study used a parallel group design undertaken over a three-year period to compare the impact of capitation payments with fee-for-service payments on primary care dentists' clinical activity. The study reported on measures of clinical activity (mean percentage of children receiving active preventive advice, health service utilisation (mean number of visits), patient outcomes (mean number of filled teeth, mean percentage of children having one or more teeth extracted and the mean number of decayed teeth) and healthcare costs (mean expenditure). Teeth were restored at a later stage in the disease process in the capitation system and the clinicians tended to see their patients less frequently and tended to carry out fewer fillings and extractions, but also tended to give more preventive advice.There was insufficient information regarding the cost-effectiveness of the different remuneration methods.

AUTHORS' CONCLUSIONS

Financial incentives within remuneration systems may produce changes to clinical activity undertaken by primary care dentists. However, the number of included studies is limited and the quality of the evidence from the two included studies was low/very low for all outcomes. Further experimental research in this area is highly recommended given the potential impact of financial incentives on clinical activity, and particular attention should be paid to the impact this has on patient outcomes.

The virtual dental home: implications for policy and strategy

Widely recognized problems with the U.S. health care system, including rapidly increasing costs and disparities in access and outcomes also exist in oral health. If oral health systems are to meet the "Triple Aim" of improving the experience of care, improving the health of populations, and reducing per capita costs of health care, new and innovative strategies will be needed including new regulatory, delivery, and financing systems. The virtual dental home is one such system.

Professional projects and institutional change in healthcare: the case of American dentistry

This paper combines resources from the organization studies and sociology literatures to advance understanding of institutional change processes in healthcare that emerge from the professionalization projects of occupations. Conceptually, we introduce a model that combines the 'archetype' approach to analyzing structural change with a framework for analyzing the agency of emergent professions. We then employ the model to frame a historical case analysis (1972-2009) of the highly contested process by which the occupation of dental hygiene in the US fought to introduce a new organizational form, the alternative practice hygiene (APH) archetype. This archetype challenges the traditional model (the dentist's office archetype) that is supported by the dominant dentistry profession. Our analysis contributes two main sets of empirical findings. First, we present a systematic comparison of the APH and Dentist's Office archetypes in terms of their belief systems, formal structures, agents, and policy implications (e.g., access to services). Second, we provide an account of the agency of dental hygienists' attempts to secure the APH model as part of their professionalization project.

Alternative practice dental hygiene in California: past, present, and future

This study examines the development of the registered dental hygienist in alternative practice in California through an analysis of archival documents, stakeholder interviews, and two surveys of the registered dental hygienist in alternative practice. Designing, testing and implementing a new practice model for dental hygienists took 23 years. Today, registered dental hygienists in alternative practice have developed viable alternative methods for delivering preventive oral health care services in a range of settings with patients who often have no other source of access to care.

Addressing children's oral health in the new millennium: trends in the dental workforce

Oral Health in America: A Report of the Surgeon General (SGROH) and National Call to Action to Promote Oral Health outlined the need to increase the diversity, capacity, and flexibility of the dental workforce to reduce oral health disparities. This paper provides an update on dental workforce trends since the SGROH in the context of children's oral health needs. Major challenges remain to ensure a workforce that is adequate to address the needs of all children. The dentist-to-population ratio is declining while shortages of dentists continue in rural and underserved communities. The diversity of the dental workforce has only improved slightly, and the the diversity of the pediatric population has increased substantially. More pediatric dentists have been trained, and dental educational programs are preparing students for practice in underserved areas, but the impact of these efforts on underserved children is uncertain. Other workforce developments with the potential to improve children's oral health include enhanced training in children's oral health for general dentists, expanded scope of practice for allied dental health professionals, new dental practitioners including the dental health aid therapist, and increased engagement of pediatricians and other medical practitioners in children's oral health. The evidence for increasing caries experience in young children points to the need for continued efforts to bolster the oral health workforce. However, workforce strategies alone will not be sufficient to change this situation. Requisite policy changes, educational efforts, and strong partnerships with communities will be needed to effect substantive changes in children's oral health.